Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery: An AAGL White Paper.

This is the first Enhanced Recovery After Surgery (ERAS) guideline dedicated to standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery. The guideline was rigorously formulated by an American Association of Gynecologic Laparoscopists Task Force of US and Canadian gynecologic surgeons with special interest and experience in adapting ERAS practices for patients requiring minimally invasive gynecologic surgery. It builds on the 2016 ERAS Society recommendations for perioperative care in gynecologic/oncologic surgery by serving as a more comprehensive reference for minimally invasive endoscopic and vaginal surgery for both benign and malignant gynecologic conditions. For example, the section on preoperative optimization provides more specific recommendations derived from the ambulatory surgery and anesthesia literature for the management of anemia, hyperglycemia, and obstructive sleep apnea. Recommendations pertaining to multimodal analgesia account for the recent Food and Drug Administration warnings about respiratory depression from gabapentinoids. The guideline focuses on workflows important to high-value care in minimally invasive surgery, such as same-day discharge, and tackles controversial issues in minimally invasive surgery, such as thromboprophylaxis. In these ways, the guideline supports the American Association of Gynecologic Laparoscopists and our collective mission to elevate the quality and safety of healthcare for women through excellence in clinical practice.

The impact of an enhanced recovery after minimally invasive surgery program on opioid use in gynecologic oncology patients undergoing hysterectomy.

OBJECTIVES: To evaluate the effects of an enhanced recovery after minimally invasive surgery (MIS-ERAS) protocol on opioid requirements and post-operative pain in patients undergoing minimally invasive hysterectomy on a gynecologic oncology service. METHODS: For this retrospective study, opioid use (oral morphine equivalents (OME)) and post-operative pain scores were compared between patients undergoing minimally invasive hysterectomy pre and post MIS-ERAS protocol implementation. Patients with chronic opioid use or chronic pain were excluded. Opioid use and pain scores were compared between groups using Wilcoxon Rank Sum, Student's t-test, and multiple linear regression. Compliance and factors associated with opioid use and pain scores were assessed. RESULTS: The MIS-ERAS cohort (n = 127) was compared to the historical cohort (n = 99) with no differences in patient demographic, clinical or surgical characteristics observed between groups. Median intra-operative and inpatient post-operative opioid use were lower among the MIS-ERAS cohort (12.0 vs 32.0 OME, p < .0001 and 20.0 vs 35.0 OME, p = .02, respectively). Pain scores among MIS-ERAS patients were also lower (mean 3.6 vs 4.1, p = .03). After controlling for age, BMI, operative time, length of stay, cancer diagnosis, and surgical approach, the MIS-ERAS cohort used 10.43 fewer OME intra-operatively (p < .001), 10.97 fewer OME post-operatively (p = .019) and reported pain scores 0.56 points lower than historical controls (p = .013). Compliance was ≥81% for multimodal analgesia elements and ≥75% overall. CONCLUSIONS: Enhanced recovery after minimally invasive surgery protocol implementation is an effective means to reduce opioid use, both in the intra-operative and post-operative phases of care, among gynecologic oncology patients undergoing minimally invasive hysterectomy.

The Association Between Mindfulness and Postoperative Pain: A Prospective Cohort Study of Gynecologic Oncology Patients Undergoing Minimally Invasive Hysterectomy.

STUDY OBJECTIVE: To describe the association between preoperative dispositional mindfulness (the personality trait of being mindful) and postoperative pain in gynecologic oncology patients undergoing minimally invasive hysterectomy. DESIGN: Prospective cohort study. SETTING: University-affiliated teaching hospital. PATIENTS: Gynecologic oncology patients (n = 126) planning minimally invasive hysterectomy. INTERVENTIONS: Minimally invasive hysterectomy. MEASUREMENTS AND MAIN RESULTS: Baseline mindfulness was assessed at the preoperative visit using the Five Facet Mindfulness Questionnaire (FFMQ). Postoperative pain and opioid usage were evaluated via chart review and surveys at postoperative visits at 1 to 2 weeks and 4 to 6 weeks. Higher baseline mindfulness was correlated with lower postoperative pain as measured by both the average and highest numeric pain scores during the inpatient stay (r = -.23, p = .020; r = -.21, p = .034). At the initial postoperative visit, pain score was also inversely correlated with preoperative mindfulness score (r = -.26, p = .008). This relationship was not observed at the final postoperative visit (r = -.08, p = .406). Pre-operative mindfulness and opioid usage were also inversely associated, though this relationship did not reach statistical significance (r = -.18, p = .066). CONCLUSION: Mindfulness was previously shown to be a promising intervention for chronic pain treatment. Our study demonstrates that higher preoperative dispositional mindfulness is associated with more favorable postoperative pain outcomes, including lower pain scores but not lower opioid consumption. This relationship provides an opportunity to target the modifiable personality characteristic of mindfulness, to reduce postoperative pain in patients following gynecologic surgery.

Opioid use after minimally invasive hysterectomy in gynecologic oncology patients.

OBJECTIVES: To quantify, and identify predictors of, post-discharge opioid use in gynecologic oncology patients undergoing minimally invasive hysterectomy (MIH). METHODS: For this prospective cohort study, gynecologic oncology patients planning to undergo MIH were recruited at a single institution. Post-operative opioid usage was evaluated via chart review and surveys at 1-2-week and 4-6-week post-operative visits. Opioids are converted to oral morphine milligram equivalents (MME) for standardization. Descriptive statistics and modified Poisson regression were used to quantify opioid requirements and evaluate predictors of post-discharge opioid use respectively. RESULTS: One hundred eighteen eligible women underwent MIH. Of these, 108 had complete data at both follow-up timepoints. Malignancy was present in 79% of cases, 71% of which were endometrial cancer. Most surgeries were laparoscopic (73%). Median hospital stay was 1 night (IQR 1-1). Inpatients received a median of 30.75 MME (IQR 7.5-52.5 MME). Twenty-three women (21.3%) used no opioids while inpatient. At the 1-2-week follow-up median usage was 6 pills of 5 mg oxycodone, or 45 MME (IQR 0-15.5 pills). After complete follow-up, median post-discharge usage was 10 pills, or 75 MME (IQR 0-22.5 pills) and 36 participants (33.33%) used no opioids after hospital discharge. The median prescription was for 30 pills (range 10-60). Above median inpatient opioid use was associated with an increased risk of above median opioid usage after hospital discharge (RR 2.31, 95% CI 1.38-3.87) on multivariable analysis. CONCLUSIONS: In this cohort, opioids were overprescribed relative to use. Inpatient use was the strongest predictor of post-discharge opioid use. More restrictive, and personalized, opioid prescribing practices may be a pathway to reduce opioid misuse and diversion. PRéCIS: Opioids were overprescribed by a factor of three to gynecologic oncology patients, whose inpatient opioid requirement predicted post-discharge opioid needs after minimally invasive hysterectomy.

Audio, video, chat, email, or survey: How much does online interview mode matter?

In the design of qualitative interview studies, researchers are faced with the challenge of choosing between many different methods of interviewing participants. This decision is particularly important when sensitive topics are involved. Even prior to the Covid-19 pandemic, considerations of cost, logistics, and participant anonymity have increasingly pushed more interviews online. While previous work has anecdotally compared the advantages of different online interview methods, no empirical evaluation has been undertaken. To fill this gap, we conducted 154 interviews with sensitive questions across seven randomly assigned conditions, exploring differences arising from the mode (video, audio, email, instant chat, survey), anonymity level, and scheduling requirements. We surveyed interviewers and interviewees after their interview for perceptions on rapport, anonymity, and honesty. In addition, we completed a mock qualitative analysis, using the resulting codes as a measure of data equivalence. We note several qualitative differences across mode related to rapport, disclosure, and anonymity. However, we found little evidence to suggest that interview data was impacted by mode for outcomes related to interview experience or data equivalence. The most substantial differences were related logistics where we found substantially lower eligibility and completion rates, and higher time and monetary costs for audio and video modes.

Adjuvant Human Papillomavirus Vaccine to Reduce Recurrent Cervical Dysplasia in Unvaccinated Women: A Systematic Review and Meta-analysis.

OBJECTIVE: To perform a systematic review and meta-analysis evaluating the efficacy of adjuvant human papillomavirus (HPV) vaccination in preventing recurrent cervical intraepithelial neoplasia (CIN) 2 or greater after surgical excision. DATA SOURCES: Electronic databases (Cochrane, PubMed, EMBASE, MEDLINE, Scopus, and ClinicalTrials.gov) were searched for studies comparing surgical excision alone to surgical excision with adjuvant HPV vaccination for CIN 2 or greater. Studies published from January 1990 to January 2019 were included. METHODS: A total of 5,901 studies were reviewed. The primary outcomes evaluated included: recurrence of CIN 2 or greater, CIN 1 or greater, and HPV 16,18 associated CIN within 6-48 months. We used Covidence software to assist with screening, and meta-analysis was performed using Review Manager. TABULATION, INTEGRATION, AND RESULTS: Six studies met inclusion criteria and were included in the final analysis. In total 2,984 women were included; 1,360 (45.6%) received adjuvant HPV vaccination after surgical excision, and 1,624 (54.4%) received either placebo or surgical management alone for CIN 2 or greater. Recurrence of CIN 2 or greater occurred within 6-48 months in 115 women (3.9%) overall; however, recurrence was significantly lower for vaccinated women: 26 of 1,360 women (1.9%) vs 89 of 1,624 unvaccinated women (5.9%) (relative risk [RR] 0.36 95% CI 0.23-0.55). The risk of CIN 1 or greater was also significantly lower with adjuvant HPV vaccination, occurring in 86 of 1,360 vaccinated women (6.3%) vs 157 of 1,624 unvaccinated women (9.7%) (RR 0.67 95% CI 0.52-0.85). Thirty-five women developed recurrent CIN 2 or greater lesions specific to HPV 16,18; nine received adjuvant vaccination (0.9%) vs 26 who were unvaccinated (2.0%) (RR 0.41 95% CI 0.20-0.85). CONCLUSION: Adjuvant HPV vaccination in the setting of surgical excision for CIN 2 or greater is associated with a reduced risk of recurrent cervical dysplasia overall and a reduction in the risk of recurrent lesions caused by the most oncogenic strains (HPV 16,18). Human papillomavirus vaccination should therefore be considered for adjuvant treatment in patients undergoing surgical excision for CIN 2 or greater. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42019123786.

Moyamoya disease in pregnancy and delivery planning: A case series and literature review.

Moyamoya disease is a rare condition characterized by stenosis or occlusion of the intracranial internal carotid arteries leading to the development of fragile collateral vessels. Disruption of these vessels can lead to both ischemic and hemorrhagic strokes. As such, these patients are sensitive to changes in intracranial pressure and pose a challenge in pregnancy and delivery planning. Two cases of a parturients with moyamoya disease are presented, and the literature regarding safe method of delivery in similar patients is reviewed. The available evidence suggests that adequate anesthesia, and maintenance of hemodynamic status, takes precedence over the exact method of delivery in these patients. Cesarean delivery under epidural anesthesia can be a safe option for parturients with moyamoya disease, but an uncomplicated vaginal delivery, most often assisted with either vacuum or forceps, has also been frequently reported.